1. 15: Diabetic Emergencies

2. Cognitive Objectives (1 of 2)
4-4.1 Identify the patient taking diabetic medications with altered mental status and the implications of a history of diabetes.
4-4.2 State the steps in the emergency medical care of the patient taking diabetic medicine with an altered mental status and a history of diabetes.
4-4.3 Establish the relationship between airway management and the patient with altered mental status.

3. Cognitive Objectives (2 of 2)
4-4.4 State the generic and trade names, medication forms, dose, administration, action, and contraindications for oral glucose.
4-4.5 Evaluate the need for medical direction in the emergency medical care of the diabetic patient.

4. Affective Objectives
4-4.6 Explain the rationale for administering oral glucose.

5. Psychomotor Objectives
4-4.7 Demonstrate the steps in the emergency medical care for the patient taking diabetic medicine with an altered mental status and a history of diabetes.
4-4.8 Demonstrate the steps in the administration of oral glucose.
4-4.9 Demonstrate the assessment and documentation of patient response to oral glucose.
Demonstrate how to complete a prehospital care report for patients with diabetic emergencies.

6. Additional Objectives
Demonstrate the steps in the use of a glucometer.
This is a noncurriculum objective.

7. Defining Diabetes (1 of 2)
Diabetes mellitus
Metabolic disorder in which the body cannot metabolize glucose
Usually due to a lack of insulin
Glucose
One of the basic sugars in the body
Along with oxygen, it is a primary fuel for cellular metabolism.

8. Defining Diabetes (2 of 2)
Insulin
Hormone produced by the pancreas
Enables glucose to enter the cells
Without insulin, cells starve.
Hormone
Chemical substance produced by a gland
Has special regulatory effects on other body organs and tissues

9. Type I Diabetes Insulin-dependent diabetes
Patient does not produce any insulin.
Insulin injected daily
Onset usually in childhood

10. Type II Diabetes Non-insulin-dependent diabetes
Patient produces inadequate amounts of insulin.
Disease may be controlled by diet or oral hypoglycemics.

11. Role of Glucose and Insulin
Glucose is the major source of energy for the body.
Constant supply of glucose needed for the brain
Insulin acts as the key for glucose to enter cells.

12. Hyperglycemia
Lack of insulin causes glucose to build-up in blood in extremely high levels.
Kidneys excrete glucose.
This requires a large amount of water.
Without glucose, body uses fat for fuel.
Ketones are formed.
Ketones can produce diabetic ketoacidosis.

13. Signs and Symptoms of Diabetic Ketoacidosis
Vomiting
Abdominal pain
Kussmaul respirations
Unconsciousness
© Jones and Bartlett Publishers. Photographed by Kimberly Potvin.

14. Blood Glucose Monitors
Glucometer
Normal range mg/dL
Test strips

15. Diabetic Emergencies According to Blood Glucose Level

16. Signs of Diabetic Coma Kussmaul respirations Dehydration
“Fruity” breath odor
Rapid, weak pulse
Normal or slightly low blood pressure
Varying degrees of unresponsiveness

17. Signs of Insulin Shock Normal or rapid respirations Pale, moist skin
Sweating
Dizziness, headache
Rapid pulse
Normal to low blood pressure
Altered mental status
Aggressive or confused behavior
Hunger
Fainting, seizure, or coma
Weakness on one side of the body

18. Patient is rocking back and forth.
You and your partner are dispatched for a 43-year-old man who is “very sweaty and acting strangely.”
Police are on scene.
Patient is rocking back and forth.
Patient repeatedly says he needs to go home.
Patient is pale, sweaty, and trembling.
You are the Provider

19. You are the Provider continued
Should this patient be allowed to refuse treatment?
What additional resources are indicated for this patient?
You are the Provider continued

20. Scene safety remains a priority. Beware of used syringes.
Scene Size-up
Scene safety remains a priority.
Beware of used syringes.
Ensure that needed resources are requested.
Consider spinal immobilization based on MOI.

21. You are the provider continued
As you assemble your equipment, your partner tells you the patient is wearing a medic alert tag.
The patient is an insulin-dependent diabetic.
The patient’s glucose level is 45 mg/dL.
What is your next step?
You are the provider continued

22. Does the patient appear anxious, restless, or listless?
Initial Assessment
General impression
Does the patient appear anxious, restless, or listless?
Is the patient apathetic or irritable?
Is the patient interacting with the environment appropriately?
If the patient has an altered mental status, summon ALS immediately.

23. Airway and Breathing Check for adequate airway; treat appropriately.
If adequate or patient has an altered mental status, provide oxygen via nonrebreathing mask at 10 to 15 L/min.
If inadequate, ensure ventilations with 100% oxygen.
A hyperglycemic patient may have:
Rapid, deep respirations (Kussmaul respirations)
Sweet, fruity breath odor

24. Circulation Warm, dry skin = diabetic coma
Moist, pale skin = insulin shock
Rapid, weak pulse = insulin shock

25. Transport Decision Depends on LOC and ability to swallow
Patients with altered mental status and impaired ability to swallow should be transported promptly.
Patients who can swallow and maintain own airway may be further evaluated and interventions performed.

26. Focused History and Physical Exam (1 of 2)
Unresponsive patients receive a rapid physical exam.
Ask patients with known diabetes:
Do you take insulin or any pills that lower your blood sugar?
Have you taken your usual dose of insulin (or pills) today?
Have you eaten normally today?
Have you had any illness, unusual amount of activity, or stress today?

27. Focused History and Physical Exam (2 of 2)
Patients who have eaten but not taken insulin are more likely to have developed diabetic ketoacidosis.
Patients who have taken insulin but have not eaten are more likely to be in insulin shock.
The patient will often know what is wrong.
Do not assume that diabetes is the cause of the problem.

28. Focused Physical Exam
Focus on patient’s mental status and ability to swallow and protect the airway.
Obtain a Glasgow Coma Scale score.
Other signs:
Tremors
Abdominal cramps
Vomiting
Fruity breath odor
Dry mouth

29. Baseline Vital Signs Hypoglycemia Respirations = normal to rapid
Pulse = normal to rapid
Skin = pale and clammy
Blood pressure = low
Hyperglycemia
Respirations = deep and rapid
Pulse = normal to fast
Skin = warm and dry
Blood pressure = normal

30. Interventions Conscious patient
If able to swallow without risk of aspiration, encourage him or her to drink juice or another drink that contains sugar.
Or administer oral glucose.
Unconscious patient
Will need IV glucose
When in doubt, consult medical control.

31. You are the Provider (continued) (1 of 2)
You help the patient self-administer the entire tube of glucose.
If the patient is hypoglycemic, how long should it take for this to begin to raise the patient’s mental status?
The patient has gotten argumentative and mildly combative. Is this expected?
You are the Provider (continued) (1 of 2)

32. You are the Provider (continued) (2 of 2)
He becomes more alert.
He tells you that he was driving home to eat because he realized that his blood sugar level was dropping.
After a few minutes, he is fully alert and refuses transport.
You remind him to eat a meal high in carbohydrates as soon as possible.
You are the Provider (continued) (2 of 2)

33. Detailed Physical Exam
The patient may have sustained trauma or may have another metabolic problem; do not make assumptions.
Perform a careful physical exam if time permits.

34. Is the patient’s mental status improving? Reassess ABCs, vital signs.
Ongoing Assessment
Is the patient’s mental status improving?
Reassess ABCs, vital signs.
If patient deteriorates, provide more glucose.
Relay information to the hospital.
Carefully document your assessment findings.
Follow local protocols for refusals.
© LiquidLibrary

35. Administering Glucose (1 of 3)
Names:
Glutose
Insta-Glucose
Dose equals one tube
Glucose should be given to a diabetic patient with a decreased level of consciousness.
DO NOT give glucose to a patient with the inability to swallow or who is unconscious.

36. Administering Oral Glucose (2 of 3)
Make sure the tube is intact and has not expired.
Squeeze a generous amount onto a bite stick.

37. Administering Glucose (3 of 3)
Open the patient’s mouth.
Place the bite stick on the mucous membranes between the cheek and the gum with the gel side next to the cheek.
Repeat.

38. Complications of Diabetes
Heart disease
Visual disturbances
Renal failure
Stroke
Ulcers
Infections of the feet and toes
Seizures
Altered mental status

39. Seizures Consider hypoglycemia as the cause.
Use appropriate BLS measures for airway management.
Provide prompt transport.

40. Altered Mental Status
Altered mental status is often caused by complications of diabetes.
Ensure that airway is clear.
Be prepared to ventilate and suction.
Provide prompt transport.

41. Alcoholism Patients may appear intoxicated.
Suspect hypoglycemia with any altered mental status.
Be aware of the similarity in symptoms of acute alcohol intoxication and diabetic emergencies.

42. Relationship to Airway Management
Patients may lose their gag reflex, causing them to be unable to guard their airway.
Be ready to manage the airway.
Place patient in lateral recumbent position and have suction available.

43. Review Insulin-dependent diabetes mellitus is a condition in which:
A. too much insulin is produced.
B. glucose utilization is impaired.
C. too much glucose enters the cell.
D. the body does not produce glucose.

44. Review
Answer: B
Rationale: Diabetes mellitus is a disease in which the pancreas fails to produce enough insulin (or none at all). Insulin is a hormone that promotes the uptake of sugar from the bloodstream and into the cells. Without insulin, glucose utilization is impaired because it cannot enter the cell.

45. Review Insulin-dependent diabetes mellitus is a condition in which:
too much insulin is produced.
Rationale: The body only produces the amount of insulin that is needed to enable glucose to enter cells.
B. glucose utilization is impaired.
Rationale: Correct answer
C. too much glucose enters the cell.
Rationale: An abnormally high blood glucose level is known as hyperglycemia.
D. the body does not produce glucose.
Rationale: Glucose is derived from the oral intake of carbohydrates. It is stored in different body structures and then metabolized by cells.

46. Review
2. A 45-year-old man with insulin-dependent diabetes is found unresponsive. Which of the following questions is MOST important to ask his wife?
A. “Did he take his insulin today?”
B. “How long has he been a diabetic?”
C. “Has he seen his physician recently?”
D. “What kind of insulin does he take?”

47. Review
Answer: A
Rationale: All of these questions are important to ask the spouse of an unconscious diabetic. However, it is critical to ask if the patient took his insulin. This will help you differentiate insulin shock from diabetic coma. For example, if the patient took his insulin and did not eat, or accidentally took too much insulin, you should suspect insulin shock. If the patient did not take his insulin, you should suspect diabetic coma.

48. Review
2. A 45-year-old man with insulin-dependent diabetes is found unresponsive. Which of the following questions is MOST important to ask his wife?
“Did he take his insulin today?”
Rationale: Correct answer
B. “How long has he been a diabetic?”
Rationale: This is useful past medical history (PMHx) information.
C. “Has he seen his physician recently?”
Rationale: This is also important history (Hx) information.
D. “What kind of insulin does he take?”
Rationale: This provides important information about a patient’s medications.

49. Review
3. A diabetic patient presents with a blood glucose level of 310 mg/dL and severe dehydration. The patient’s dehydration is the result of:
A. excretion of glucose and water from the kidneys.
B. a deficiency of insulin that causes internal fluid loss.
C. an infection that often accompanies hyperglycemia.
D. an inability to produce energy because of insulin depletion.

50. Review
Answer: A
Rationale: In severe hyperglycemia, the kidneys excrete excess glucose from the body. This process requires a large amount of water to accomplish; therefore, water is excreted with the glucose, resulting in dehydration.

51. Review
3. A diabetic patient presents with a blood glucose level of 310 mg/dL and severe dehydration. The patient’s dehydration is the result of:
excretion of glucose and water from the kidneys.
Rationale: Correct answer
B. a deficiency of insulin that causes internal fluid loss.
Rationale: A lack of insulin will cause the glucose level to rise and it is the glucose that causes the fluid loss.
C. an infection that often accompanies hyperglycemia.
Rationale: An infection is an invasion of the body by an organism — glucose is not a foreign element.
D. an inability to produce energy because of insulin depletion.
Rationale: A body’s inability to metabolize glucose does not cause a fever.

52. Review
4. Which combination of factors would MOST likely cause insulin shock in a diabetic patient?
A. Eating a meal and taking insulin
B. Skipping a meal and taking insulin
C. Eating a meal and not taking insulin
D. Skipping a meal and not taking insulin

53. Review
Answer: B
Rationale: The combination that would most likely cause insulin shock is skipping a meal and taking insulin. The patient will use up all available glucose in the bloodstream and become hypoglycemic. Left untreated, insulin shock may cause permanent brain damage or even death.

54. Review
4. Which combination of factors would MOST likely cause insulin shock in a diabetic patient?
Eating a meal and taking insulin
Rationale: This process will maintain the body’s glucose level.
B. Skipping a meal and taking insulin
Rationale: Correct answer
C. Eating a meal and not taking insulin
Rationale: Eating will cause the glucose levels to rise.
D. Skipping a meal and not taking insulin
Rationale: Glucose levels should remain the same but may be influenced by the patient’s metabolic rate or physical activities. This does not cause insulin shock.

55. Review
5. A 19-year-old diabetic male was found unresponsive on the couch by his roommate. After confirming that the patient is unresponsive, you should:
A. suction his oropharynx.
B. manually open his airway.
C. administer high-flow oxygen.
D. begin assisting his ventilations.

56. Review
Answer: B
Rationale: Immediately after determining that a patient is unresponsive, your first action should be to manually open his or her airway (eg, head tilt-chin lift, jaw-thrust). Use suction as needed to clear secretions from the patient’s mouth. After manually opening the airway and ensuring it is clear of obstructions, insert an airway adjunct and then assess the patient’s breathing.

57. Review
5. A 19-year-old diabetic male was found unresponsive on the couch by his roommate. After confirming that the patient is unresponsive, you should:
suction his oropharynx.
Rationale: After opening the airway, suction as needed to remove any secretions.
B. manually open his airway.
Rationale: Correct answer
C. administer high-flow oxygen.
Rationale: After opening the airway, provide oxygen if the patient’s breathing is adequate.
D. begin assisting his ventilations.
Rationale: After opening the airway, assist with ventilations if the patient’s breathing is inadequate.

58. Review
6. What breathing pattern would you MOST likely encounter in a patient with diabetic ketoacidosis (DKA)?
A. Slow and shallow
B. Shallow and irregular
C. Rapid and deep
D. Slow and irregular

59. Review
Answer: C
Rationale: Kussmaul respirations—a rapid and deep breathing pattern seen in patients with diabetic ketoacidosis (DKA)—indicates that the body is attempting to eliminate ketones via the respiratory system. A fruity or acetone breath odor is usually present in patients with Kussmaul respirations.

60. Review
6. What breathing pattern would you MOST likely encounter in a patient with diabetic ketoacidosis (DKA)?
Slow and shallow
Rationale: Agonal respirations are seen with cerebral anoxia and may have an occasional gasp.
B. Shallow and irregular
C. Rapid and deep
Rationale: Correct answer
D. Slow and irregular
Rationale: Biot respiration results from increased intracranial pressure and can also have periods of apnea.

61. Review
7. A woman called EMS because her 12-year-old son, who had been experiencing excessive urination, thirst, and hunger for the past 36 hours, has an altered mental status and is breathing fast. You should be MOST suspicious for:
A. low blood sugar.
B. hypoglycemia.
C. insulin shock.
D. diabetic coma.

62. Review
Answer: D
Rationale: The child is experiencing diabetic coma secondary to severe hyperglycemia. Diabetic coma is characterized by a slow onset; excessive urination (polyuria), thirst (polydipsia), and hunger (polyphagia). Other signs of diabetic coma include rapid, deep breathing with a fruity or acetone breath odor (Kussmaul respirations); a rapid, thready pulse; and an altered mental status.

63. Review
7. A woman called EMS because her 12-year-old son, who had been experiencing excessive urination, thirst, and hunger for the past 36 hours, has an altered mental status and is breathing fast. You should be MOST suspicious for:
low blood sugar.
Rationale: Low blood sugar does not cause frequent urination.
B. hypoglycemia.
Rationale: Hypoglycemia is low blood sugar.
C. insulin shock.
Rationale: Insulin shock does not produce any of these symptoms.
D. diabetic coma.
Rationale: Correct answer

64. Review
8. If the cells do not receive glucose, they will begin to metabolize:
A. fat.
B. acid.
C. sugar.
D. ketones.

65. Review
Answer: A
Rationale: If the body’s cells do not receive glucose, they will begin to metabolize the next most readily available substance—fat. Fat metabolism results in the production of ketoacids, which are released into the bloodstream (hence the term “ketoacidosis”).

66. Review
8. If the cells do not receive glucose, they will begin to metabolize:
fat.
Rationale: Correct answer
B. acid.
Rationale: Fatty-acids are a bi-product (waste product) of the metabolism of fat.
C. sugar.
Rationale: Sugar is glucose.
D. ketones.
Rationale: Ketones are a bi-product (waste product) of the metabolism of fat.

67. Review 9. In contrast to diabetic coma, insulin shock:
A. rarely presents with seizures.
B. presents over a period of hours to days.
C. should not routinely be treated with glucose.
D. usually responds immediately after treatment.

68. Review
Answer: D
Rationale: Insulin shock usually responds immediately following treatment with glucose. Patients with diabetic coma generally respond to treatment gradually, within 6-12 hours following the appropriate treatment. Seizures can occur with both diabetic coma and insulin shock, but are more common in patients with insulin shock.

69. Review 9. In contrast to diabetic coma, insulin shock:
rarely presents with seizures.
Rationale: Insulin shock can produce seizures.
B. presents over a period of hours to days.
Rationale: Insulin shock has a rapid onset of symptoms (possible minutes).
C. should not routinely be treated with glucose.
Rationale: Insulin shock is always treated with glucose.
D. usually responds immediately after treatment.
Rationale: Correct answer

70. Review
10. Patients with diabetic ketoacidosis experience polydipsia because:
A. they are dehydrated secondary to excessive urination.
B. the cells of the body are starved due to a lack of glucose.
C. fatty acids are being metabolized at the cellular level.
D. hyperglycemia usually causes severe internal water loss.

71. Review
Answer: A
Rationale: Severe hyperglycemia—which leads to diabetic ketoacidosis—causes the body to excrete large amounts of glucose and water. As a result, the patient becomes severely dehydrated, which leads to excessive thirst (polydipsia).

72. Review
10. Patients with diabetic ketoacidosis experience polydipsia because:
they are dehydrated secondary to excessive urination.
Rationale: Correct answer
B. the cells of the body are starved due to a lack of glucose.
Rationale: True, but the lack of glucose does not cause thirst.
C. fatty acids are being metabolized at the cellular level.
Rationale: Fats are metabolized by the cells instead of glucose which produces acids and ketones, thus the term ketoacidosis.
D. hyperglycemia usually causes severe internal water loss.
Rationale: This is false. It causes water loss due to glucose being excreted (externally) in the urine solution.